Email Infrastructure Checklist for Healthcare and Compliance

Ensure business associate agreements include breach notification timelines, audit rights, subcontractor controls, and data residency aligned with your policies.

Tag intake addresses, headers, and routing rules for PHI vs non-PHI, and enforce dedicated pipelines for clinical messages to prevent cross-contamination.

Set WORM retention for audit logs and parsed JSON, and document legal hold escalation paths for investigations without exposing PHI unnecessarily.

Limit credentials to specific domains and APIs, require MFA, and implement break-glass procedures with approval workflows for emergency access.

Define steps for misdirected PHI, credential compromise, and delivery failures, including containment, forensic logging, and privacy office notifications.

Validate certifications (e.g., SOC 2, HITRUST), encryption practices, key management, and subcontractor chains for all components touching email content.

Use a clinical-intake domain to segregate PHI traffic from general mail, set low TTLs for rapid failover, and document the accepted sender list.

Publish a strict MTA-STS policy and ingest TLS-RPT reports to detect downgrade attacks or misconfigurations affecting PHI email flows.

Minimize spf include statements, remove wildcard sources, and test alignment to reduce spoofing risks for clinical subdomains.

Rotate DKIM keys via KMS and restrict key access, ensuring signature alignment with the intake domain to strengthen trust and policy enforcement.

Route aggregate and forensic reports to monitored mailboxes or APIs, redacting identifiers and filtering external shares to protect PHI.

Separate bounces for clinical workflows, capture delivery diagnostics without PHI, and throttle retry policies to avoid mail loops.

Block inbound SMTP that cannot negotiate approved TLS versions, and log downgrade attempts for investigation.

Parse multipart boundaries strictly, disallow obscure encodings, and quarantine messages with anomalous nesting that can bypass scanners.

Scan for PHI indicators such as MRN formats, ICD codes, and name-DOB pairs, then route positives to quarantined storage with limited access.

Decode Base64 and Quoted-Printable, preserve critical headers, and include message IDs, timestamps, and routing metadata for audits.

Accept only approved types (e.g., PDF, JPEG), remove macros and embedded scripts, and record sanitization actions in the audit trail.

Use separate keys for PHI, rotate at least every 90 days, and track key IDs per artifact to support targeted revocation.

Require client certificates and HMAC signatures with rotating secrets, rejecting requests that fail signature or certificate validation.

Prevent duplicate processing by hashing canonical JSON and persisting a deduplication key with expiration policies.

Throttle webhook deliveries and queue consumption based on downstream health signals to maintain stable clinical operations.

Separate operational errors from data policy breaches, enforce limited access, and require case notes before reprocessing.

Include schema version fields, support rolling upgrades, and publish deprecation timelines to avoid breaking clinical integrations.

Emit correlation IDs linking SMTP hops to API calls, enabling forensic reconstruction and SLA tracking for compliance audits.

Generate test emails that mimic clinical patterns and verify parsing accuracy, DLP catches, and schema outputs in CI/CD.

Simulate cipher negotiation failures and strip attempts, confirming the pipeline fails closed and alerts appropriately.

Review aggregate and forensic reports, confirm policy alignment, and adjust sending sources to maintain high authentication rates.

Model appointment reminders, referrals, and imaging PDFs to ensure latency targets and queue depth thresholds hold under stress.

Rehearse DNS changes, relay switchover, and queue draining, documenting RTO/RPO results for compliance reporting.

Confirm sensitive fields are masked in application logs, metrics, and traces, and spot check sampling configurations.

Store ingestion, parsing, and delivery logs in tamper-evident systems with retention matching regulatory requirements.

Detect and notify when parsed content flows to non-clinical queues or unauthorized webhooks, and auto-quarantine affected messages.

Create proactive alerts for expiring certs and spikes in TLS errors to avoid unencrypted intake or delivery interruptions.

Publish dashboards and SLOs, and tie alerts to patient-impact thresholds such as appointment reminders or lab result flows.

Document triage steps, escalation paths, and communication templates, and conduct periodic drills with realistic scenarios.

Evaluate control effectiveness, refresh risk assessments, and update policy mappings for evolving regulations and system changes.